| Entity Name: | BEACHES BEHAVIORAL MEDICINE, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 21 May 2014 (11 years ago) |
| Document Number: | P14000045677 |
| FEI/EIN Number | 47-1026373 |
| Address: | 230 Canal Blvd Suite 2, Ponte Vedra Beach, FL 32082 |
| Mail Address: | 230 Canal Blvd Suite 2, Ponte Vedra Beach, FL 32082 |
| ZIP code: | 32082 |
| County: | St. Johns |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1417309832 | 2016-07-09 | 2023-01-12 | PO BOX 1557, PONTE VEDRA BEACH, FL, 320041557, US | 1351 13TH AVE S STE 120, JACKSONVILLE BEACH, FL, 322503237, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 904-280-6701 |
| Fax | 9042806702 |
Authorized person
| Name | DR. JUSTIN KUHNS SPOONER |
| Role | PRESIDENT |
| Phone | 9042806701 |
Taxonomy
| Taxonomy Code | 207QA0401X - Addiction Medicine (Family Medicine) Physician |
| License Number | ME115625 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2083A0300X - Addiction Medicine (Preventive Medicine) Physician |
| Is Primary | No |
| Taxonomy Code | 2084A0401X - Addiction Medicine (Psychiatry & Neurology) Physician |
| Is Primary | No |
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| Is Primary | No |
| Taxonomy Code | 2084P0804X - Child & Adolescent Psychiatry Physician |
| Is Primary | No |
| Taxonomy Code | 2084P2900X - Pain Medicine (Psychiatry & Neurology) Physician |
| Is Primary | No |
| Taxonomy Code | 208VP0000X - Pain Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 208VP0014X - Interventional Pain Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 00863244100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DURANT SCHOEPPEL & DECUNTO PA | Agent | 6550 ST AUGUSTINE ROAD SUITE 105, JACKSONVILLE, FL 32204 |
| Name | Role | Address |
|---|---|---|
| Spooner, Justin K, M.D. | President | 230 Canal Blvd Suite 2, Ponte Vedra Beach, FL 32082 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G23000059684 | BEACHES BEHAVIORAL MEDICINE INC | ACTIVE | 2023-05-11 | 2028-12-31 | No data | 230 CANAL BLVD SUITE 2, PONTE VEDRA BEACH, FL, 32082 |
| G21000028049 | BEACHES SPINE AND PAIN | ACTIVE | 2021-02-27 | 2026-12-31 | No data | 230 CANAL BLVD, SUITE 2, PONTE VEDRA BEACH, FL, 32082 |
| G21000028050 | BEACHES BEHAVIORAL MEDICINE | ACTIVE | 2021-02-27 | 2026-12-31 | No data | 1351 13TH AVENUE SOUTH SUITE 120, JACKSONVILLE BEACH, FL, 32250 |
| G19000013718 | BEACHES SPECIALTY GROUP PA | EXPIRED | 2019-01-25 | 2024-12-31 | No data | 230 CANAL BLVD, SUITE 2, PONTE VEDRA BEACH, FL, 32082 |
| G18000062210 | JAX PRIMARY CARE AND PAIN MANAGEMENT | EXPIRED | 2018-05-24 | 2023-12-31 | No data | 2550 PARK STREET, JACKSONVILLE, FL, 32204 |
| G16000045172 | BEACHES LASER SPINE AND PAIN MEDICINE | EXPIRED | 2016-05-04 | 2021-12-31 | No data | 1411 SOUTH 14TH ST SUITE A, FERNANDINA BEACH, FL, 32034 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2023-02-17 | 230 Canal Blvd Suite 2, Ponte Vedra Beach, FL 32082 | No data |
| CHANGE OF MAILING ADDRESS | 2023-02-17 | 230 Canal Blvd Suite 2, Ponte Vedra Beach, FL 32082 | No data |
| REGISTERED AGENT NAME CHANGED | 2021-03-08 | DURANT SCHOEPPEL & DECUNTO PA | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-03-08 | 6550 ST AUGUSTINE ROAD SUITE 105, JACKSONVILLE, FL 32204 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-12 |
| ANNUAL REPORT | 2023-04-18 |
| ANNUAL REPORT | 2022-07-20 |
| ANNUAL REPORT | 2021-04-05 |
| Reg. Agent Change | 2021-03-08 |
| ANNUAL REPORT | 2020-01-17 |
| ANNUAL REPORT | 2019-02-06 |
| ANNUAL REPORT | 2018-06-28 |
| ANNUAL REPORT | 2017-03-19 |
| ANNUAL REPORT | 2016-03-26 |
Date of last update: 21 Jan 2025
Sources: Florida Department of State
